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2:00 am: While on call, the Coronary Care Unit (CCU) intern pages you regarding a hypotensive patient. The nurse started the patient on 2 pressors without orders. You rush to assess the patient. When you reach the CCU, you find that both the nurse and the intern are upset. The nurse is concerned that there are no orders. The intern is concerned that the nurse started the second pressor without his order. You are more concerned as to why the patient is hypotensive. Meanwhile, the senior admitting CCU resident is watching a movie on his phone.

Does this situation sound familiar? Every cardiology fellow has been faced with an equally frustrating situation at some point in time. Conflict is part and parcel of any workplace. Sometimes, the most challenging aspect of our job is not the work itself, but rather dealing with the people involved. Marquid and Huston (1) defined conflict as an internal discord that results from differences in ideas, values, priorities, perspectives, and feelings between 2 or more people. It is essentially an expression of differences (2). If unresolved, workplace conflicts can result in frustration, demoralization, resentment, and decreased productivity of the team. Although “interpersonal and communication skills” has been identified as 1 of the 6 core competencies in residency and fellowship training, most programs do not have a formal agenda or training program to address this competency (3). Most often, any focus is on communication with patients—such as how to deal with an angry patient—and not on how to communicate with colleagues.

The cardiac intensive care unit is a perfect breeding ground for conflict. It is a stressful environment, where individuals come from different backgrounds and have varied levels of clinical expertise. As Andy Teach wrote in “From Graduation to Corporation” (4), “When you have individuals coming from all different backgrounds merging together in the workplace, conflict is inevitable.” No other place epitomizes this dynamic better than the CCU. Cardiology fellows often lead the CCU team. Sometimes, we are called upon to resolve a conflict between 2 team members, and sometimes, we are part of the conflict ourselves. In either scenario, learning how to identify and cope with conflict with finesse and poise goes a long way in making us into better leaders. Our aim should not be to eliminate conflict, but instead to embrace it and skillfully move the conflict dynamic toward a positive outcome for all those involved (5).

Handling Conflict: What Is Your Style?

The first step in handling conflict is to understand your own ingrained style. Identifying and being aware of your personal style will help in consciously assessing and changing the style if required to suit the needs of a given situation. Saltman et al. (6) described the following 4 styles of dealing with conflict:

1. Avoidance. This is the most common style that people use to deal with conflict. It is simple, and does not take any effort. You remain passive and let others do what they want. Avoidance can be a reasonable approach when the matter at hand is trivial and temporary. However, this is not the best strategy on a long-term basis or for serious issues. Taking a passive approach and suppressing your feelings may also result in self-victimization.

2. Accommodation. In this style, you consistently listen to and accept the other person’s viewpoint. You are not assertive enough. This strategy is most useful when you know that you are wrong and are losing. Again, like avoidance, this is not a style you want to adopt when the situation demands a healthy discussion that might affect patient care.

3. Competition. In this style of conflict management, you do not consider the other person’s point of view. You are ready to forcibly defend your ideas. This style is sometimes seen on the CCU rounds, when the fellow and the attending are incessantly arguing a management decision based on the latest evidence versus personal experience to such an extent that the residents feel uncomfortable and confused. This is generally not a favored approach, as it can drastically disrupt the team dynamics.

4. Collaboration. For most situations, this is the best style of conflict management. You negotiate with the other person and find an amicable solution to the problem. You defend your opinions, but at the same time are not argumentative. This approach is not often used, as it is time consuming and requires not only patience but also superior verbal and communication skills. This style enables a healthy debate, leads to better insights from varied viewpoints, and more importantly, resolves the conflict with no residual or lingering resentment or animosity.

Tips for Developing a Collaborative Management Style

Developing a collaborative management style is by no means an easy job. It requires patience and honing of interpersonal communication skills. There is no single magic formula that applies to all situations. The following are some useful tips that I have learned during my CCU rotations and through self-reflection:

1. Use a common goal to negotiate. One advantage inherent in working in the CCU, is that all of the team members have one single goal in mind: patient safety. Every individual makes decisions that he/she feels is the best for the patient. Differences in our opinions and assessments on how to accomplish this common goal often drive the conflict. However, we can use our common goal of patient care and safety as the anchoring point for negotiating and resolving conflicts among team members.

2. Do not be an escalator. Most of the time, people can and should try to resolve issues among themselves. Escalating or complaining to a supervisor on the first instance a conflict arises, without first discussing it directly with the other person, is an inappropriate way to approach a problem. Turning a molehill into a mountain will only result in resentment toward the complainer. Speaking directly with your coworkers and providing immediate feedback will often solve the issue amicably. For example, in the scenario mentioned previously, where the resident was watching a movie and not helping the intern deal with a hypotensive patient, it is best to provide direct feedback during or immediately after the situation, rather than complain to the chief resident or the attending. Of course, if the situation is not resolved through direct feedback, then you may need to seek a supervisor’s help.

3. Choose words carefully. The words we use form the crux of an effective collaborative strategy. Avoid using superlatives (e.g., always, never, worst) and accusatory suggestions, as both these strongly suggest blame and encourage the other person to retaliate (7). Telling the resident, “You are always watching movies on your call and never helping your intern” is likely to elicit a defensive response. Instead, saying “I noticed that the intern may need more help. Between the two of us, let us figure out how we can best accomplish this” might elicit a more positive reaction. This is also a more collaborative approach. Using “we” or “us” is often helpful in bringing out and enhancing the team spirit. When I arrived in the CCU and found the patient was hypotensive, I said, “I need to first think why the patient is hypotensive.” This statement offended the nurse as she interpreted it to mean that nurses do not think. I wish I had used “we” instead of “I”. Choosing the right words and language in a tense situation is challenging and requires a calm and measured effort. However, the effort is worth it, as it also changes the way we think about conflicts, thus making negotiation much simpler.

4. Self-reflect and solicit feedback. Self-reflection is a powerful tool in every fellow’s growth and professional development. It gives us an opportunity to consciously and critically look at our actions in terms of assessing the situation, emotions, and responses of all of the people involved. It enables us to set goals and expectations, and take corrective actions for improving our performance next time. Most programs have self-reflection as part of periodic evaluations. These self-assessment forms provide a template to discuss challenging situations with your mentor or program director and solicit constructive feedback, further enhancing your professional growth.

In summary, being a CCU fellow provides immense opportunities to hone conflict management skills and develop into an outstanding leader. How we handle conflict sets the tone for the entire team. We should strive to create an environment where all team members solicit constructive feedback, and embrace conflict resolution as a means of professional development.

RESPONSE: A Lifelong Challenge: Conflict Resolution

Dr. Mallidi identifies a lifelong challenge: how do we deal with colleagues when there are differences of opinion, adverse outcomes, and disputes that may impact patient care? To quote Mallidi, “Sometimes, the most challenging aspect of our job is not the work itself, but rather dealing with the people involved.” On the basis of my experience in clinical medicine, this is a basic truth, and a collegial working environment is a foundation for enhanced patient care. The tips provided to deal with these issues are thoughtful and helpful. I would offer additional tips as follows:

1. Be sure you have all of the facts before responding. This means you must listen to all points of view.

2. Mutual respect is particularly important with the increasing diversity of health care teams. Hospital practice has changed dramatically with the new rules regarding resident working hours. We now have advanced practitioners taking on more responsibility and also relying more on nursing staff to deal with increasingly complex patients admitted to our hospitals. Doctors need to listen carefully to all, but particularly to the nurses providing the actual “hands-on care” of the patient. Young physicians would do well to treat experienced CCU nurses with great respect, and to seek and listen to their input carefully. I trained many years ago in a setting where the head nurse rounded with physicians on every patient. I would suggest morning rounds are incomplete without hearing from the nurse directly involved with an individual patient.

3. Say the same thing to whomever you speak. Do not modify conclusions/statements based upon the person with whom you are speaking. This will haunt you as the process of resolution evolves.

We are indebted to Dr. Mallidi for a timely reminder of the importance of how we deal with each other in the complexities of clinical medicine.

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